Nursing Elites

1. A client with asthma develops respiratory acidosis. Based on this diagnosis, what should the nurse expect the client's serum potassium level to be?

• A. normal
• B. elevated
• C. low
• D. unrelated to the pH

Correct answer: B

Rationale: In respiratory acidosis, the body retains CO2, leading to increased hydrogen ion concentration and a drop in blood pH. As pH decreases, serum potassium levels increase due to the movement of potassium out of cells to compensate for the acidosis. Elevated serum potassium levels are expected in respiratory acidosis. Choice A ('normal') is incorrect because potassium levels are expected to be elevated in respiratory acidosis. Choice C ('low') is incorrect as potassium levels rise in this condition. Choice D ('unrelated to the pH') is incorrect as serum potassium levels are directly impacted by changes in pH in respiratory acidosis.

2. When caring for a client with a possible diagnosis of placenta previa, which of the following admission procedures should the nurse omit?

• A. perineal shave
• B. enema
• C. urine specimen collection
• D. blood specimen collection

Correct answer: B

Rationale: The correct answer is 'enema.' Administering an enema to a client with placenta previa can dislodge the placenta, leading to an increased risk of bleeding and complications. It is crucial to avoid any interventions that may disrupt the placenta's positioning. Collecting urine and blood specimens are necessary for diagnostic purposes and monitoring, while a perineal shave is a routine procedure that does not pose a risk to the client with placenta previa.

3. What is an appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus?

• A. Insertion of a Foley catheter.
• B. Performing an in-and-out catheter specimen for urinalysis.
• C. Obtaining a voided urine specimen for urinalysis.
• D. Ordering a urinalysis by the physician.

Correct answer: D

Rationale: When a client presents with suspected genitourinary trauma and visible blood at the urethral meatus, obtaining a voided urine specimen for urinalysis is an appropriate intervention. This helps assess for any urinary tract injuries or abnormalities without further traumatizing the area. Insertion of a Foley catheter (Choice A) should be avoided as it can worsen the existing trauma. Performing an in-and-out catheter specimen (Choice B) involves unnecessary manipulation and can increase the risk of complications. Ordering a urinalysis by the physician (Choice D) may delay the assessment compared to obtaining a direct voided urine specimen.

4. Which symptoms is the client who overdosed on barbiturates most likely to exhibit?

• A. Bradypnea and bradycardia
• B. Hyperthermia and drowsiness
• C. Hyperreflexia and slurred speech
• D. Tachycardia and psychosis

Correct answer: A

Rationale: The correct answer is bradypnea and bradycardia. Barbiturates are central nervous system (CNS) depressants, which will slow down the respiratory rate (bradypnea) and heart rate (bradycardia). Choice B, hyperthermia and drowsiness, is incorrect as barbiturate overdose typically does not cause hyperthermia but rather hypothermia. Hyperreflexia and slurred speech (Choice C) are more indicative of stimulant overdoses rather than CNS depressants like barbiturates. Tachycardia and psychosis (Choice D) are also not typically seen in barbiturate overdose, as these drugs tend to depress the CNS rather than cause symptoms of increased heart rate or psychosis.

5. The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?

• A. 15 seconds
• B. 3 minutes
• C. 5 minutes
• D. 15 minutes

Correct answer: B

Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes. Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.

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